Obtain range of motion (ROM) first then proceed to strengthening. In general, it takes about 6-8 weeks for the tendon tissue to heal enough to begin strengthening. Therefore we have to be careful with the range of motion exercises in that first phase of therapy which is 6-8 weeks. Remember that the goal of the first 6-8 weeks is to not re-tear the rotator cuff and get some ROM (a shoulder with an intact rotator cuff with some stiffness is easier to manage than a shoulder with re-torn rotator cuff with dysfunction). The patient is allowed to use the operative arm for waist level activities such as using a computer, countertop level activities, and personal hygiene care but is to do no lifting, pushing or pulling with the arm nor reaching behind one’s back. Shoulder immobilizer/sling needs to be worn when sleeping or when outside the home for the first 6-8 weeks. When the patient is at home, the sling should be worn when they are up and walking around but may be removed when they are seated. Most patients are more comfortable sleeping in a recliner for the first few weeks, but may sleep in a bed when comfortable. While sleeping the patient is to place a pillow or a stack of blankets under the elbow and arm of the operative extremity in order to have the arm/shoulder in the plane of the body (extension of the shoulder is both painful and stresses the repair).
A multimodal approach is used to manage the discomfort which typically includes NSAID’s like ibuprofen, ice or cryotherapy, and narcotics. It is preferable to discontinue the use of narcotics as soon as possible and switch to Tylenol or other less addictive medications.
The second phase of therapy focuses on regaining the remaining range of motion deficits, including internal rotation, and the initiation of strengthening. At no point should the patient be asked to use a UBE machine or cycling with the arms because this is a repetitive activity that stresses the repair. Pain medication of some sort can be taken prior to therapy. The patient should perform their stretching program 1 time per day for the first 6 weeks and then 2 times per day after the 6 week point until FROM is obtained. Their strengthening program should be performed every other day once it is started. Expect maximum medical improvement 5-6 months after surgery. It is important to note that everyone is not the same, nor are all rotator cuff tears the same or repaired the same fashion. Everyone progresses at different rates depending on age, past medical history, current health status, smoking, etc…These are only guidelines and not set in stone. If the patient is not progressing as he/she should, please contact us.
The patient with concomitant frozen shoulder can be a very difficult situation. This is more common in diabetics and middle aged females but can occur in males as well. Sometimes we have to treat these shoulders in a staged fashion by performing extensive releases first and obtaining FROM and then coming back at a later date and performing the repair. If the ROM loss is severe this is probably the best option but if the ROM loss is mild, we may elect to do the releases and the repair at the same time to try to save the patient from a second operation. The only caveat is that the therapy afterward might be difficult as the patient is more prone to getting stiff again secondary to the pre-existing frozen shoulder. If this is the case, we may ask that the passive ROM be near full immediately postop but this will be relayed to you. Frozen shoulder is common in some patients and is not the fault of the patient or therapist.
